GAP pays up to a maximum of 230% of the SRR for specialist services in hospital, excluding pathology,

Transcription

1 Managed Care Plan Managed Care Plan offers the following comprehensive benefits: Unlimited hospital cover paid at 100% of the Scheme Reimbursement Rate (SRR) GAP pays up to a maximum of 230% of the SRR for specialist services in hospital, excluding pathology, radiology, auxiliary services and GPs performing specialist services (230% = 100% SRR + additional 130% of SRR) A Medical Savings Account for out-of-hospital services and discretionary spend Unlimited Radiology and Pathology Frail care where clinically required Extensive chronic medication Voluntary use of a GP network (no co-payments) Reimbursement for specialist consultations and procedures out-of-hospital up to 125% of SRR Contributions are split as follows: 75% goes to the Hospital Benefit or major medical benefit 25% goes to savings, for discretionary spend Excluding Savings Main member: R2 850 Adult dependant: R2 850 Child dependant: R660 Contributions Savings Main member: R950 Adult dependant: R950 Child dependant: R220 Total contributions Main member: R3 800 Adult dependant: R3 800 Child dependant: R880 MAAGED CARE 52 53

2 Managed Care Plan Benefits unless PMB Medical Savings Account Example: How to calculate your Family Limit Adult R1 000 Child R200 General hospital services Radiology and Pathology unlimited at 100% of SRR Internal surgical prosthesis R per beneficiary GAP Cover Up to a maximum of 230% of SRR Excludes pathology, radiology and auxiliary healthcare services in hospital x 2 = R2 000 x 1 = R200 Family Limit R2 200 Use the combined available limit for one or more family members Medical Savings Account Discretionary spend for out-of-hospital services and top-up of Limits below Dentistry Family Limit Adult: R3 320 / Child: R1 245 Radiology Unlimited Pathology Unlimited Medical and Surgical Appliances Limit R per family Wheelchair Every 2 years R per beneficiary Hearing Aids Every 2 years R per pair per beneficiary Chronic Medication (non-pmb) R per beneficiary Frail Care R per beneficiary The annual Medical Savings Account (MSA) allocation is made available to you in January (in advance for the year) and offers the flexibility to pay for: on-pmb GP and specialist consultations and procedures Acute medicine, including Pharmacist Advised Therapy (PAT) medicine Eye care, spectacles, lenses and contact lenses Dental services including orthodontic treatment (after your basic dentistry benefit has been exhausted) Chiropractic services Homeopaths, naturopaths and osteopaths, including medicine Chiropody and podiatry Out-of-hospital physiotherapy Audiology Speech and occupational therapy Clinical psychology Dietitian services Social worker and other auxiliary services Certain co-payments and charges above SRR (excluding PMBs) can be considered for payment from your MSA. This is a once-off instruction. Members may request reimbursement for Scheme exclusions or non-pmb chronic medication co-payments from their available MSA. The Scheme needs to be instructed in every instance. Contact the Scheme on or download the form from >Info Centre > Downloads > Application forms. Any unspent savings belong to the member and roll over to the next year. Positive savings carried forward from previous years allow you to build up a healthy savings balance for a time when you need extra medical cover

3 How it works To call an ambulance Phone etcare 911 on If deemed an emergency, etcare will authorise a road or air ambulance. In a medical emergency where authorisation was not obtained, you need to provide details to etcare 911 the next working day after the incident. If no authorisation has been obtained within 48 hours, you will be responsible for the costs. To obtain authorisation Procedures, treatments, hospitalisation, external medical or surgical appliances. Call to get authorisation for procedures, treatments, hospitalisation, internal surgical prosthesis and external medical appliances exceeding R1 000, before the event as indicated in the benefit table. Remember: o authorisation, no benefit. Information required when calling for authorisation: Membership number Date of admission ame of the patient ame of the hospital Type of procedure or operation, diagnosis with CPT code and the ICD-10 code (obtainable from the doctor) The name of your doctor or service provider and the practice number. This authorisation number must be quoted on admission. It will be valid for a period of four months or until the end of the year, whichever comes first. Please phone if any of the details change such as the date of operation, code etc. If the admission is postponed or not taken up before it becomes invalid, a new authorisation number will need to be obtained. ou will have no co-payment if the condition is a PMB. Chronic medicine If you are diagnosed with a chronic condition (PMB or non-pmb), ask your doctor or pharmacist to register the chronic condition by calling We will then pay for your medicine from the relevant chronic medicine benefit and not from your day-to-day benefits. Diabetes and HIV/AIDS management: Register on the programme to ensure maximum benefits: Diabetes call the Centre for Diabetes and Endocrinology (CDE) on HIV/AIDS management call One Health on To reduce your medicine costs Visit > Managed Care Plan > Medicines to find a Scheme Preferred Pharmacy near you for lower medicine prices and reduced co-payments

4 To claim Ensure your claim is valid, you have received the treatment or services you have been charged for and that the following details are correct and complete: Full name of main member Membership number ame of patient (main member or dependant) ame of provider and practice number Details of the service rendered (tariff code, CPT code and explanation) The diagnosis code (ICD-10) The treatment date Proof of payment if you have settled your account Send your completed claim to: Post: Anglo Medical Scheme, PO Box 746, Rivonia, 2128 Call: for further assistance Upload: after logging in as a member ou need to provide a letter of undertaking to refund the Scheme for any amounts paid on your behalf where a third party is responsible for payment. ou or your service provider have up to four months after the treatment date to submit a claim for payment. After four months, it will be considered stale and the Scheme will no longer be responsible for payment. Keep all receipts so you can claim back from your personal tax and keep a copy in case the originals get lost. After submission of your claim, the Scheme will: otify you by SMS or once your claim has been processed (if you have subscribed to this service) Pay all amounts according to the Scheme Rules and at the Scheme Reimbursement Rate (SRR) Pay this amount directly into your bank account (or the provider s account) Send you a statement by or post showing amounts paid, to whom, rejections and amounts for you to settle We can only process your claims if all details are legible. Fax submissions are therefore not recommended. If you still prefer to fax the claims, please send them to Third-party claims (for example, the Road Accident Fund) are not the responsibility of the Scheme. Emergency treatments will be paid, but will need to be refunded. our responsibility Check the statement if payments have been made correctly Check rejections on your statements. If a mistake has been made, correct the claim and resubmit within 60 days Settle any outstanding amounts with your service provider

5 Overseas travel Emergency and acute medical treatment received when travelling overseas The Scheme can reimburse you, in accordance with the Rules and necessary authorisations, at the SRR: The Scheme will not pay a doctor or service provider outside RSA borders directly. ou must pay for the services at the time of the treatment and the Scheme will refund you Submit a fully specified account, in English, to the Scheme The account must give details of the service rendered and state the relevant health care provider The Scheme will pay the rand value according to the SRR had the service been provided in South Africa. Remember that except in the case of a medical emergency, the normal authorisation procedure needs to be followed before undergoing any routine or specialised treatment overseas We suggest you take out adequate medical travel insurance to cover any major medical emergency. GP network ou can choose to consult a GP on our administrator s general practitioner (GP) network. Claims for consultations will be submitted directly to the Scheme and be paid from your MSA or by the Scheme if PMB. The amount the GP will claim for a consultation is a fixed rate, as agreed between our administrator and the network GP. This rate will be available from the Call Centre on Before changing to a network GP, compare your current doctor s rate to the network rate. In some instances the network rate might be higher. our network GP may also perform certain procedures (as per the network agreement) which will be submitted directly to the Scheme and be paid from your MSA or by the Scheme if PMB. our network GP will not ask you for payment upfront, nor charge you a co-payment on consultations and most procedures. If the network GP performs a procedure not agreed with the administrator, or uses medicines or materials that are charged above the Scheme Reimbursement Rate (SRR), there may be a co-payment. Choosing to consult a GP on this network is voluntary. Chronic medicine advanced supply For an advanced supply of chronic medicine, please submit: A completed advanced supply form (available on A prescription covering the period A copy of your ticket or itinerary Call for further assistance. The list of agreed procedures is available on the Scheme website or from the Call Centre. ou can find the nearest participating GP using the provider search tool on after logging in as a member, or by calling the call centre. If you choose to use a GP that is not on the network, the Scheme will reimburse your consultations and procedures at the normal SRR

6 Preventative Care Benefits To support you in managing your health proactively, we encourage you to take preventative measures. Detecting health risks or a disease early could prevent a disease or at least improve the success rate of the treatment. The below preventative care benefits are paid by the Scheme (not from your normal benefits) at the Scheme Reimbursement Rate. Refer to the benefit table for more detail. The following preventative care measures are recommended, and will be paid from your relevant benefit limit or Medical Savings Account at the Scheme Reimbursement Rate or negotiated rate or cost if PMB. Please discuss your individual need with your doctor. Refer to the benefit table for more detail. Description Sex Age* Benefit Category Purpose Bone density scan F 65+ Specialised Radiology Detection of osteopenia or osteoporosis (fragile bones) Colonoscopy F/M 50+ Endoscopy** Early detection of colorectal or colon cancer HIV test F/M All Pathology Early detection of HIV/AIDS Immunisation Human Papillomavirus (HPV): Cervarix / Gardasil Flu Vaccine F/M All Vaccines Pneumococcal Vaccine F/M 55+ Vaccines F 9-26 Vaccines Prevention of cervical cancer caused by HPV Influenza prevention; particularly important for people who are at risk of serious complications from influenza (chronic conditions, pregnant, HIV patients or ageing members) Prevention of serious lung infections; particularly important for people who are at high risk for serious complications (chronic conditions, HIV patients or ageing members) Mammogram F 40+ Specialised Radiology Early detection of breast cancer Maternity Consultation Ultrasound F Maternity F Maternity Monitoring of your pregnancy and prevention of complications Pap smear F Pathology Early detection of cervical cancer Pathology screening Cholesterol Glucose Thyroid F/M All Pathology Early detection of chronic illness Description Sex Age* Paid from Purpose Eyesight check Including Glaucoma screening Dental check-up F/M All F/M 40+ Member savings Dental benefit or member savings Gynaecological check-up F All Member savings Hearing test F/M All Member savings Immunisation children As recommended by the Department of Health, GP or paediatrician Baby and child Paediatric assessment F/M F/M As per schedule Baby/ Child Member savings Member savings Early detection of eye disease or deterioration Early detection of dental disease and preservation of dentine Early detection of cancer and gynaecological problems Early detection of medical conditions and hearing dysfunction Prevention and reduction of complications of childhood diseases Early detection of developmental problems Prostate check-up (examination) M 50+ Member savings Early detection of prostate cancer Senior members Home nursing assessment on Doctor or Scheme request F/M 65+ Member savings Detection of complications or mobility problems negatively impacting on wellbeing or illness Podiatry Care F/M All Member savings Skin health F/M All Member savings Detection of skin cancer Stool test (cancer and other screening) F/M 50+ Pathology Detection of cancer and other diseases Prostate check-up (blood test) M 50+ Pathology Early detection of prostate cancer Vitality check Cholesterol Blood glucose (Sugar) BMI Blood pressure F/M All Vitality check Early detection of chronic illness * recommended age unless you have specific risk factors ** co-payments may apply in hospital * recommended age unless you have specific risk factors 62 63

7 Benefits All benefits paid at 100% of SRR, GAP, negotiated rate or at cost if PMB What you are entitled to (per annum) Is authorisation * Limit** Is programme Designated service provider Savings or scheme account IH In-hospital Out-of-hospital Comments and co-payments Alcohol and drug treatment programme, including hospitalisation and medication in hospital 21 days in hospital SACA and SACA approved facilities Scheme to pay IH Alcohol and drug treatment programme including consultations and medication outside hospital Available savings SACA and SACA approved facilities Member savings If you do not register on the SACA programme, you may continue using your existing provider, but you will be responsible for the difference between the amount charged and the amount the Scheme would have paid to SACA Alternative healthcare: Acupuncture, chiropody, chiropractic services, homeopathy, naturopathy Available savings Member savings Ambulance services: Life-threatening medical emergency transport etcare 911 Scheme to pay otify etcare 911 the next working day after the emergency if authorisation was not obtained at the time of the incident. Authorise inter-hospital transfers before the event Auxiliary services: Audiology, dietitians, occupational therapy, orthoptics, physiotherapy, podiatry, psychology, social services, speech therapy Available savings Member savings Out-of-hospital services only (Physiotherapy, psychology and related services provided in support of in-hospital procedures are paid by the Scheme and not from member savings. Scheme protocols apply) Cancer treatment: Oncology Management Programme Scheme to pay IH 100% of SRR and Single Exit Price (SEP) for medicines. Subject to treatment protocols. Drug therapies used for chemotherapy side effects and pain relief must be authorised. Post-oncology treatment will be recognised as part of your oncology treatment which need to be registered separately * unless otherwise specified ** PMB rules apply 64 65

8 What you are entitled to (per annum) Is authorisation * Limit** Is programme Designated service provider Savings or scheme account IH In-hospital Out-of-hospital Comments and co-payments Consultations outside hospital: Specialist and GPs for chronic PMB conditions Scheme to pay Subject to Scheme protocols and of chronic condition ( required for cancer, renal, HIV and diabetes Consultations outside hospital: GP for treatment of general conditions Available savings Member savings Paid at SRR. Cost in excess of SRR can be paid from available savings upon special request Consultations outside hospital: GP for treatment of general conditions (GPs within the Discovery GP network) Available savings GP network Member savings etwork rate for consultations, paid directly by the Scheme, no co-payment, see page 61 Consultations in hospital: Specialist consultations and procedures when hospitalised Scheme to pay IH Up to 230% of SRR or in full if a PMB Consultations outside hospital: Specialist for treatment of general conditions (excluding Radiologists and Pathologists Available savings Member savings Up to 125% of SRR or in full if a PMB Dental hospitalisation: In the case of trauma, patients under the age of 7 years requiring anaesthetic and the removal of impacted molars and maxillofacial, oral surgery (PMB conditions), medicine and related products Scheme to pay IH Up to 230% of SRR for specialist services or in full if PMB Dentistry: Conservative treatments including fillings, x-rays, extractions and oral hygiene. Specialised treatments including crowns, bridges, inlays, study models, dentures, orthodontics, osseo-integrated implants or similar tooth implants and periodontics Family Limit Adult: R3 320 Child: R1 245 Scheme to pay IH Claims in excess of the limit or the SRR may be paid from your savings account. Once dental benefit is depleted, payment will be allocated to available MSA. Implants done in hospital require authorisation * unless otherwise specified ** PMB rules apply 66 67

9 What you are entitled to (per annum) Is authorisation * Limit** Is programme Designated service provider Savings or scheme account IH In-hospital Out-of-hospital Comments and co-payments Diabetes: Consultations with doctors, dietitians, ophthalmologists, podiatrists, medicine and related products CDE Scheme to pay IH Register on the Diabetes Programme with the Centre for Diabetes and Endocrinology (CDE) to receive medicines, testing equipment and related treatments according to the programme. If you choose not to register with CDE, you may continue using your existing doctor, but you will be liable for a co-payment of 20% on all the diabetic-related services including diabetic related hospitalisation Endoscopy: Gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy used to investigate the digestive system o t e Scheme to pay IH o co-payment if performed in a day clinic. For a list of accredited facilities please call the call centre or visit Co-payment of R3 350 if admitted to hospital specifically for investigations requiring an endoscopy o t e Eye care: Eye examinations, lenses, frames and contact lenses Available savings Member savings 100% of cost. See page 5 for information on discounts through the optometry network Eye care: Cataract surgery with intra-ocular lens replacement Intra-ocular lens subject to the Internal Surgical Prosthesis Limit o t e Scheme to pay IH o co-payment when performed out-of-hospital. For a list of accredited facilities please call the call centre or visit Co-payment of R1 000 when performed inhospital o t e Frail care: Medically related frail care services where clinically appropriate R per beneficiary Scheme to pay According to Scheme protocols. Only registered or Scheme approved facilities or services provided at home supervised by a registered ursing Practitioner Hearing aids (1 pair every 2 years) R per hearing aid per beneficiary every 2 years Scheme to pay Clinical motivation by ET required for beneficiaries younger than 60 years HIV/AIDS: Confidential management programme and medicine Optipharm Scheme to pay After with One Health, your medicine will be delivered by Optipharm ( ) to your place of choice. Once registered, members must adhere to Scheme protocols. our status will at all times remain confidential * unless otherwise specified ** PMB rules apply 68 69

10 What you are entitled to (per annum) Is authorisation * Limit** Is programme Designated service provider Savings or scheme account IH In-hospital Out-of-hospital Comments and co-payments Hospice: Instead of hospitalisation (in-patient care facility and out-patient home care) Hospice Scheme to pay IH Subject to Scheme protocols Hospitalisation: Hospital services including day cases, blood transfusions, radiology and pathology, professional services, 7 day supply of to-take-home medication Unlimited Scheme to pay IH Co-payment of R355 per day to a maximum of R1 065 for non-pmb admissions. otify the Scheme the next working day if authorisation was not obtained at the time of the admission Hospitalisation: Internal surgical prosthesis R per beneficiary Scheme to pay IH Hospitalisation: Step-down and private nursing instead of hospitalisation Scheme to pay IH Subject to Scheme protocols Hospitalisation: Psychiatric admission 21 days Scheme to pay IH Kidney disease: Dialysis (haemo or peritoneal) Scheme to pay IH Subject to Scheme protocols Maternity: Consultations and 2D ultrasound scans 12 consultations and 2 ultrasound scans (2D) per pregnancy Scheme to pay IH Register between weeks 12 and 20 of the pregnancy to qualify for benefits Maternity: Confinement Scheme to pay Confinement in hospital or in a low-risk maternity unit provided by a registered midwife if preferred Medical appliances: External appliances Medical and Surgical Appliance Family Limit: R per family Scheme to pay IH Authorisation required for appliances over R1 000 each Medicines: Acute medicine and injection material, homeopathic and PAT medicine Available savings Member savings 100% of SEP and dispensing fee * unless otherwise specified ** PMB rules apply 70 71

11 What you are entitled to (per annum) Is authorisation * Limit** Is programme Designated service provider Savings or scheme account IH In-hospital Out-of-hospital Comments and co-payments Medicines: Chronic conditions (PMB) Except HIV/ AIDS and diabetes Scheme to pay One month s supply at a time, 100% of SEP and dispensing fee, subject to Reference Price List. Generic medicine, where appropriate, will prevent co-payments. Check generic alternatives and co-payments on > My Plan > MCP > Medicines. Subject to Scheme protocols. Registration by pharmacist or doctor PMB chronic conditions Addison s Disease Chronic Obstructive Pulmonary Disorder Epilepsy Parkinson s Disease Asthma Coronary Artery Disease Glaucoma Rheumatoid Arthritis Bipolar Mood Disorder Crohn s Disease Haemophilia Schizophrenia Bronchiectasis Diabetes Insipidus Hyperlipidaemia Systemic Lupus Erythematosus Cardiac Failure Diabetes Mellitus Type 1 Hypertension Ulcerative Colitis Cardiomyopathy Disease Diabetes Mellitus Type 2 Hypothyroidism Chronic Renal Disease Dysrhythmias Multiple Sclerosis * unless otherwise specified ** PMB rules apply 72 73

12 What you are entitled to (per annum) Is authorisation * Limit** Is programme Designated service provider Savings or scheme account IH In-hospital Out-of-hospital Comments and co-payments Medicine: Additional chronic conditions (non-pmb) R per beneficiary Scheme to pay One month s supply at a time, 100% of SEP and dispensing fee, subject to Reference Price List. Generic medicine, where appropriate, will prevent co-payments, Check generic alternatives and co-payments on >My Plan > MCP >Medicines. Subject to Scheme protocols. Registration by pharmacist or doctor on-pmb chronic conditions Acne Degeneration of the Macula Motor euron Disease Polyneuropathy Allergy Management Depression Muscular Dystrophy and other inherited myopathies Psoriasis Alzheimer s Disease Diverticulitis arcolepsy Pulmonary Intestinal Fibrosis Anaemia Fibrous Dysplasia Obsessive Compulsive Disorder Restless Leg Syndrome Ankylosing Spondylitis Gastro-oesophageal Reflux Disease (GORD) Osteoarthritis Sarcoidosis Anxiety Disorder Gout (chronic) Osteopaenia Systemic Sclerosis Atopic Dermatitis (Eczema) Hidradenitis Suppurativa Osteoporosis Tourette s Syndrome Attention Deficit Disorder Huntington s Disease Paget s Disease Trigeminal euralgia Auto-immune Disorders Liver Disease Pancreatic Disease Urinary Calculi Cystic Fibrosis Meniere s Disease Peptic Ulcer Urinary Incontinence Cystitis (chronic) Migraine Polymyositis Organ transplant: Harvesting of the organ, post-operative care of the member and the donor and anti-rejection medicine Scheme to pay IH All costs for organ donations for any person other than to a member or registered dependant of the Scheme are excluded * unless otherwise specified when recognised as chronic according to Scheme protocol ** PMB rules apply 74 75

13 What you are entitled to (per annum) Is authorisation * Limit** Is programme Designated service provider Savings or scheme account IH In-hospital Out-of-hospital Comments and co-payments Oxygen therapy: At home, cylinder and concentrator (Rental only) VitalAire Scheme to pay Subject to the Scheme clinical entry criteria. ou are responsible for the difference in cost when using a non-designated Service Provider Pathology: (PMB) Chronic disease conditions Scheme to pay IH Subject to Scheme protocols and of the chronic condition Pathology: Out-of-hospital (non-pmb) Scheme to pay The Scheme will not pay for DA testing and investigations, including genetic testing for familial cancers and paternal testing. Members may claim these from their savings Procedures in rooms: Minor procedures by doctors in rooms Scheme to pay Subject to Scheme protocols Procedures in rooms: Specialist procedures performed in rooms instead of in hospital Scheme to pay Procedure specific. Up to 230% of SRR. Subject to Scheme protocols Radiology: General services Scheme to pay IH Specialised Radiology: MRI, CT scan and isotope therapy, bone densitometry and mammogram Scheme to pay IH Vaccine: Influenza (Flu) Scheme to pay Vaccine: Pneumococcal Scheme to pay 1 scan for bone densitometry and 1 mammogram per beneficiary 1 vaccine and 1 consultation per beneficiary. Recommended for high risk patients (chronic conditions, HIV patients, pregnant or ageing members) 1 vaccine and 1 consultation per beneficiary over the age of 55 per lifetime. Recommended for high risk patients (chronic conditions, HIV patients or ageing members) Vaccine: Human Papillomavirus (HPV) 1 lifetime vaccination Scheme to pay For female beneficiaries from 9-26 years unless motivated by your doctor Vitality check: Cholesterol, Blood Glucose, BMI, Blood Pressure Scheme to pay 1 per beneficiary per year. Vitality check done at Vitality partners or employer wellness day Wheelchair (1 wheelchair every 2 years) R per beneficiary Scheme to pay Authorisation is required for appliances over R1 000 each * unless otherwise specified ** PMB rules apply 76 77

14 Ex gratia General exclusions Members may apply for benefits in addition to those provided in the Rules. An application will be considered by the Scheme which may assist members by awarding additional funding. These awards are granted in cases of exceptional clinical circumstances or extreme financial hardship. Decisions do not set precedent or determine future policy as each case is dealt with on its own merits. Call or download the ex gratia application form at Submit the completed application form: or Fax: or Post: The Ex Gratia Department, P.O. Box 746, Rivonia 2128 Upon approval submit your claims: or Fax: or Post: Anglo Medical Scheme, P.O. Box 746, Rivonia 2128 The following are some of the Scheme exclusions (for a full list please refer to the Rules). These you would need to pay: Services rendered by any person who is not registered to provide healthcare services, as well as medicine that have been prescribed by someone who is not registered to prescribe Experimental or unproven services, treatments, devices or pharmacological regimes Patent and proprietary medicines and foods, including anabolic steroids, baby food and baby milk, mineral and nutritional supplements, tonics and vitamins except where clinically indicated in the Scheme s managed care protocols Cosmetic operations, treatments and procedures, cosmetic and toiletry preparations, medicated or otherwise Obesity treatment, including slimming preparations and appetite suppressants Examinations for insurance, school camps, visas, employment or similar Holidays for recuperative purposes, regardless of medical necessity Interest or legal fees relating to overdue medical accounts Stale claims, which are claims submitted more than four months after the date of treatment Claims for appointments that a member fails to keep Costs that exceed any annual maximum benefit and costs that exceed any specified limit to the benefits to which members are entitled in terms of the Rules 78 79

15 All costs related to: - Anaesthetic and hospital services for dental work (except in the case of trauma (PMB), patients under the age of seven years and the removal of impacted third molars) - Bandages, dressings, syringes (other than for diabetics) and instruments - Lens preparations - DA testing and investigations, including genetic testing for familial cancers and paternal testing - Gum guards, gold in dentures, gold used in crowns, inlays and bridges - Immunoglobulins except where clinically indicated against the Scheme s protocols - I n vitro fertilisation, including GIFT and ZIFT procedures, and infertility treatments which are not PMBs - Organ donations to any person other than to a member or registered dependant - Sports injuries arising from professional sport, speed contests or speed trial - Wilful self-inflicted injuries 80 81

16 Contact us GEERAL Principal Officer PO Box 62524, Marshalltown 2107 Ex gratia applications Fraud hotline (Ethics line) Web Visit to learn more about your Scheme and benefits and register as a member to access your membership information 24/7. VALUE CARE PLA anglo@primecure.co.za Ambulance services Chronic authorisation and Claims HIV/AIDS management programme Authorisation and health advice Please call me line STADARD & MAAGED CARE PLA Ambulance services etcare (emergency) Administration Call Centre Overseas calls Chronic authorisation and Oxygen management Authorisation Third party claims department General enquiries: member@angloms.co.za Claims claims@angloms.co.za Fax (not recommended) P.O. Box 746, Rivonia 2128 Diabetes management Centre for Diabetes and Endocrinology (CDE) PO Box 2900, Saxonworld 2132 members@cdecentre.co.za HIV/AIDS Management Programme One Health anglo@onehealth.co.za Clinical Emergencies Chronic medicine Optipharm WALK-I CETRES Cape Town Knowledge Park Heron Crescent Century City Durban 41 Imvubu Park Place River Horse Valley Business Estate Johannesburg 16 Fredman Drive Sandton Port Elizabeth Coega BPO Park Zone 4 Coega, IDZ 6001 Pretoria Highveld Techno Park Cnr Oak and Tegel Avenue Centurion